Is refeeding syndrome common? with Dr Kylie Matthews-Rensch APD

refeeding syndrome really interested me because as you mentioned before, there's not a great deal of evidence, no one really knows what they're doing. It's all it's very confusing. I sometimes I don't know where anyone's pitch their numbers from I don't even know where Australia has picked their numbers from. We've got a conservative bunch of clinicians. And then the guidelines aren't made up on research. Most of them are based on expert opinions. So if you've got experts that are cautious, then of course, they're going to recommend cautious recommendations. When I was a student, the number of times I had to pay the doctor to tell them that I thought a patient was at risk of refeeding syndrome was borderline ridiculous, like I can't believe I used to harass the medics so much, Dr. Kelly Matthews, she's a dietitian. She's also a researcher. And it all started when she disagreed with the placement supervisor so much about if a patient had refeeding syndrome and she decided to go ahead and get a PhD in the topic. Kelly is a dietitian based in Queensland, Australia, who graduated from Griffith University in 2014 and completed her PhD in refeeding syndrome in 2018. I don't know anyone who knows more about refeeding syndrome and Kaylee during this podcast, we discuss her journey and her thoughts as to whether all dieticians should pursue PhDs. This conversation is likely to challenge your current practices around refeeding syndrome and help you understand more about this area. If you are a dietitian who works with patients who could be or are at risk of refeeding syndrome. This is a must listen podcast. So without further ado, my name is Aaron Boysen. This is the dietetics digest podcast. So ensure you chew it thoroughly as there's a lot to digest here.

Think you were first brought to my attention from your presentation you did for the dietitian network on refeeding syndrome based upon work you did in your masters and PhD. I'm thrilled to have you on the podcast today. I'd love to get someone's background and understand why they originally went into dietetics. Because I think that informs a lot about their thought process and who they become as a dietitian. So what originally interested you into becoming a dietitian, so I never actually planned to be a dietitian, I all through high school, I thought I wanted to be a doctor. So I did my undergrad in biomedical science. And I actually flew down to Melbourne to have my interview to get into medicine. And on my flight home, I decided I didn't want to do it. So I withdrew my application. And for a couple of years, I bounced around ideas. I did a year of psychology. I thought about doing veterinary science. And then all of a sudden one day I woke up and realised I love food. And I love science and why don't I put those two together? So I went on and did my masters very next year was dietetics, something you were always exposed to did you wake up that morning and think I love food, I love science and then have to research how you could use those two interests. But it was actually my friend Jenny from high school, she was debating her own career, and she was tossing out all the different Allied Health Professions. So she was leaning towards social work. And then she's our dietetics sounds really cool. So does occupational therapy. And I just think dietetics stuck in my brain from that very random conversation. So you went on to do your master's in dietetics. And then you eventually you went on to choose to do a PhD and further research. Why did you choose to do that pathway? Why didn't you just go straight into work and actually working with people and food I never planned to it's actually funny, I get a yearly reminder on Facebook that I posted that I would never do a PhD when I was in the middle of my master's research.

I did my master's research because I didn't like the other streams through uni through the Master's course, I think there was a business stream and there was a community stream and I thought, Oh, no research would be really nice. And then in our programme, we were offered a variety of different topics. And someone said, you don't want to go with Michelle Palmer unless you're going to really put in 100%. And I was like I could totally put in 100% and refeeding syndrome really interested me because as you mentioned before, there's not a great deal of evidence, no one really knows what they're doing. So I thought it would be really great to just go into that and have a look.

Michelle was a hard worker. She was a hard supervisor. And I can say that because she went on to be my PhD advisor and I love it a bit. And she knows I say this sort of stuff. But she originally while I was going through that suggested that I would be good for a PhD candidate. And that stuck with me and then it's really quite difficult to get into the workforce here. I always knew I wanted to be a hospital clinician. I think a lot of students do. And then it just seemed like a really good option and I could work one day a week while I was doing my PhD at the hospital that Michelle works at. So I got a nice balance, having some clinical work while doing my PhD. Sounds like someone always bet you to do wondering that you shouldn't go, Michelle, unless you're gonna work hard. And you're just like, I can work right? I can do that. But you telling me that you assume I don't want to work hard. Against this,

I see rid of my PhD actually ran my first full marathon just to really shred my entire body. Just

and the PhD, what was the experience like doing a PhD? I think similar to most people that go through a PhD the first year, you work really hard. And then as soon as you get through your candidate show you have a little lull, my allow lasted a while. So I would do work for a few hours every day, and then really have to stop myself from having an app and keep working. And then you get to the last year of it, and you're like not, I gotta punch it out. So I actually started, I did it. The opposite way to most people actually started working full time in the last six months of my PhD. So I really had to work extremely hard to get it over the line and finish the writing part of it. There were times when it was hard to keep up the motivation, I made sure that I went to conferences and that sort of thing to really keep that level of some motivation going. And for dietitians out there, working around the world and things like that student dieticians and younger dietitians, so do you think it helps you as a dietitian to have the PhD background? I think it is helpful if you love research, and you want to keep doing research. So my PhD has opened a lot of doors for me, I've been asked to present internationally, like at Aspen last year, which was really lovely. I've been able to act up at work in the research coordinator roles and that sort of thing. But I also work in a department that has a lot of dieticians with PhDs. And because we all want to do research, we also really need those people that just love to do clinical work, because researchers are always going to want to do research, I love a bit of a mix of clinical work and research work. But I know not all researchers are like that. So I think it's important to just focus on what you really want to do. And don't just do a PhD because someone looks impressive, because they've done it. I've actually really, to be honest, that's a really interesting response. Because I feel like sometimes a lot of people who from the PhD background are very encouraging. And I don't know a little bit like they, they really want everyone to do PhDs and they think it's for everybody, however, but when I talk to people on the ground, there's loads of dieticians who are amazing clinicians, amazing for patients really just fantastic people. But they really don't enjoy the research side. And I think even some of them have been pushed to do masters because of pressures at work or having a certain role. And that being a requirement and just not enjoying that side of the role and actually just really enjoying the patient work. And they sometimes feel a little bit frustrated by the constant feeling they need to do more research, get more qualifications, and it feels a bit. I don't know, it feels a little bit uncomfortable for them PhDs a long time. And if you're not enjoying it, then life is so short, is just look around with COVID and everything. If you're not doing something that you aren't, there's no point I've watched people do their PhDs that haven't really wanted to do it and they've come so close, they've either dropped out or they've come so close to dropping out, they've had to take a lot of time off and then really push themselves to finish it. And they're not going to do research again after it's done. Because they just it's tainted now. So I think it's Yeah, I think it's important to really think about what you want out of your career. Yeah, there's some amazing clinicians out there that just don't want to borrow research and I have a lot of respect for them that they're sticking to their guns and doing what they love. And they're fantastic in that way. And I think, yeah, I think we're gonna get better clinicians and better dieticians and happier dietitians if we just let people work to their skill set, instead of just making everyone fit in a in a square hole. So what made you go into refeeding syndrome? What made you focus in on that area in particular dietetic practice, so I remember when I was on my placement for Masters, this was after I'd done my research project, I was on my emplacement and I was seeing a patient with my supervisor, and I recommended one sausages in a day to this patient because she was struggling to eat. I didn't think she was at risk of refeeding syndrome. But my supervisor did and I got a fair amount of trouble for recommending the surgeon daily. And I found that really frustrating because it's very different now with Oral nutrition compared to when we think of like the prisoners of war, who were suddenly given something when they hadn't had anything for a very long time. Most people that come into our hospitals here in Australia now, they haven't been starved. For months or years, they've maybe had two weeks of slightly poor oral intake, and then someone's realised and walk them to hospital if they haven't bought themselves in. So I thought, because I was so frustrated, I am a complainer, I will admit that I complain to my fellow students on placement. And er, I just realised refeeding syndrome really needs a lot of research done in it. And I felt really passionate that day, like I felt range and felt we did a PhD to prove her wrong. Yeah, pretty much that and Michelle Obama loves it. And my other primary advisor, she hates it, I'm just really pushing them with Sandra Capra. Because she never wanted to look at refeeding syndrome, it probably helped in the development of the PhD and the research, if you have that sort of back and forth between different individuals that are there to support you. Yeah, it was really wonderful, actually. Because I will admit, when I started my PhD, I thought refeeding syndrome was a lot more common than I do now. So it was nice to see that. Also, because I am also stubborn, I will admit that I'm mentioning all my faults to you today aren't that changing my own mind over that course was really nice as well. And I think having two very different opinions in my advisors was helpful for that too. Definitely. So just so we can get a little bit of a set the scene, could you explain a little bit about what is refeeding syndrome? Or how would you explain what refeeding syndrome is. So in simplest terms, I like to say that refeeding syndrome comes about because we have a patient that comes into hospital, who is severely malnourished, and their body is in a state of catabolism. When we start giving them nutrition, any type of nutrition, oral enteral, or parenteral, the body brief kicks back into what it should be doing. And that means because our body stores have our electrolytes our time and everything is so low from being severely malnourished, those levels plummet even further, because our bodies using them to work through that food. So using glucose in particular, which is why people talk about monitoring how much carbohydrate you're giving these patients who are at risk. So refeeding syndrome is I like to always remind people, it's a combination of signs and symptoms. It's not just hypophosphatemia, which a lot of people will Bandy about. It's also hypokalemia, hypomagnesemia, FireMon deficiency and all the symptoms that come along with that it can be edoema, as well. And it doesn't have to be all of those together. Is it easy to diagnose refeeding syndrome? Would you be able to see it on someone? Or do you just make a sort of educated guess based on the symptoms? They're presenting with a collection of symptoms? You've just started feeding after a period of starvation? Is that how you deduce if it's refeeding syndrome or not? Or is there anything you can say for sure? Is refeeding syndrome? Or is it just really just an educated guess a set of signs and symptoms? In my mind, it's an educated guess there's no consensus on definitions anywhere. When I talked to doctors in the hospital, they just named the three electrolytes and they say if it's low, that's refeeding syndrome. And I really do disagree with that train of thought, I think that sometimes your electrolytes are going to drop. And because we'll never get through ethics, you're never going to know how if they'll like drop and naturally lift back up as nutrition increases. But I think it's a natural part of restarting nutrition, that doesn't mean that you're going to the full blown refeeding syndrome. When I did my, I did a case study. For my PhD, I looked back at the case histories of patients that have died in Queensland with refeeding syndrome listed on their death certificate. And we only found five across 20 years. And when I read through the case notes, there was only one of those patients that I actually was like, Oh my God, that person actually did die with refeeding syndrome. They had a lot of other issues going on as well. So it's hard to say whether refeeding syndrome with the primary cause but yeah, that one was really obvious to me, whereas the others, I was just like, I don't think this is it at all. And I got really excited. It sounds bad, but I got really excited when I was reading that case. Because like that, that is what I've been looking for. And I don't see it and I obviously feel really horrible for that patient and the patient's family that I would get excitement out of reading that case but is so rare in a hospital system that has so much support that can do daily bloods that can give supplementation to patients easily and that sort of thing. What do you think about the term? I've heard it described as biochemical refeeding syndrome? Is that even a thing? Or is that just made up being that I've heard that term bandied around quite a bit for disturbances and electrolytes and just calling it biochemical refeeding? syndrome? Yeah, yeah, I look, I don't mind the term, I just find that most people just hear the refeeding syndrome part and just roll with it. So I'm always very cautious of using too many times for one, one issue. So because, you know, we've got refeeding, hypervelocity. Sorry, refeeding, hyperphosphatemia, and then we've got refeeding syndrome and biochemical refeeding syndrome. And we've got general refeeding, like as in refeeding, our patients, but some people when they see refeeding, they think it's refeeding syndrome. And it just gets very messy. I think. So. But I do agree with the premise of the biochemical refeeding. And, obviously, based on what you're saying, is very different than a lot of the guidance around the world. I'm quite familiar with nice guidance, and we've got other guidance for different conditions such as eating disorders, where do you think this this sort of caution comes from? Well, why are we so cautious? In such a way we know malnutrition is probably way more prevalent than refeeding syndrome? Why are we so cautious when we're refilling our patients? Where does that caution come from? Do you think? I think, for one, no one wants to be the dietician that killed someone with refeeding, because they let them go into refeeding syndrome. The second is that a lot of the cases, I think that people will refer back to cases that weren't managed well, and they weren't managed well, because we didn't have the research to show us what to do. So there were the two cases in the very early 80s, with the parenteral nutrition and everyone references those. But the latest, the RCT that was recently published in November shows us that no, we don't need to be that scared of parenteral nutrition provided we are giving supplementation and that sort of thing. And when I talk about refeeding syndrome, and I'm explaining how bad it can be to people that haven't heard of it before, I always refer back to the prisoners of war, because they're actual, those were actual cases, like when you're reading the literature, you're like, Oh, yes, that is legit. That prisoner of war was in a concentration camp for years, and then they were let out and someone very kindly fed them. And that was it. And I think as a profession as well, we are cautious bunch, like, we're basically all type A, we like to follow rules, we've got a conservative bunch of clinicians, and then the guidelines aren't made up on research. Most of them are based on expert opinion. So if you've got experts that are cautious, then of course, they're going to recommend cautious recommendations. Definitely, I remember I had a student on placement with me, and we're going through a patient and she was quite concerned about this patient was a risk of refeeding syndrome. And our trust guidance were based, similar to nice guidance, just so everyone can get an example that were going through the guidelines. And she felt that because the patient was at risk of refeeding syndrome, she thought maybe I should be even more cautious than Nice. However, thanks to your presentation, I was able to explain a little bit around kind of like the evidence and things like that she was able to understand, maybe I shouldn't be more cautious than Nice. Yeah, long. Stories like that make me really sad for our patients, because you know that if they're underpaid, they're generally in hospital for a lot longer, and we're exacerbating their malnutrition. So, always trying to remind people of that, like, you're probably doing more harm than good. By sitting back and panicking about that we can generally fix so if the electrolytes start dropping, we can give something definitely. And that study your reference previously, I will have that study in the show notes and it's a study it's a randomised control trial, correct me if I'm wrong, a randomised control trial, looking at parenteral nutrition, high and low feeding. I'm not sure how they defined it. And looking at markers for refeeding syndrome. Yes, that's the one. Yeah, so I'll share that in the show notes. So that brings us on to guidelines and the variation in guidelines around the world. However, there's one variation that sort of brings my attention every single time and I've always wondered about it, is the variation between nice and marzipan. And they seem to move around back and forth playing with each other on two opposite ends of the spectrum. They move back and forth all the time. And I know that I think they're working on another revision of marzipan coming up in the summer this year. They're probably sitting around discussing at the moment they're probably wanting to move in another direction or move back and forth. Why is this? Why is they're just paying a little bit of almost playing like a game with each other until the opposite ends of the spectrum, why are they doing this? From your assessment? I wish I knew. So I sometimes I just I don't understand why patients with eating disorders can generally be fed higher calories when they've probably been starving for longer than the nice criteria, which is little or no intake for five days. Yeah, it still blows my mind, we can double the intake for these patients that have been starving themselves for potentially years. But we have to be really cautious with our 88 year old who hasn't eaten properly for five days. So who's had a low BMI for her entire life? And it's not because she stabbed herself. It's just because she's a tiny little lady. So yeah, it's frustrating. And I get why clinicians will then default to the more conservative option. So if they say this, these guidelines say this, and these guidelines say this, and the second set of guidelines say something a bit more conservative, they seem safer. So why not default to five calories per day to start feeding? Yeah, I think probably also nice makes it a little bit more confusing with little to no intake, what does that actually mean? Or more expert opinion. It is funny, though, because I read them. And I think our Australian New Zealand guidelines are quite, they're a bit more assertive than both of marzipan and nice. So we actually start for our patients with medically compromised eating sores, we actually start feeds it just over 6000 kilojoules per day. So no matter what their BMI is, and that sort of thing, and then advanced up to 12,000 kilojoules. So yeah, there is variation everywhere. 6000 kilojoules and calories is that. So that's a sorry, I can't I go back and forth. And it's very confusing. So about 1500 calories per day. 100. Yeah, and then the new aspirin recommendations that came out. They also they're quite similar to nice and they're starting rate. So they say start between 10 and 20 calories per kilo. But then they say you can advance up a bit faster as you can go up 33% towards go right every day or two. It's all it's very confusing. I sometimes I don't know where anyone's pitch their numbers from I don't even know where Australia has picked their numbers from I just know that I like it, because it's a little bit more assertive than some of the other countries. But yeah, they're all they are all different, which is disappointing, because you'd like to think that we can all practice the same way. Especially in Australia, Europe, UK, Australia. So did I say America was the first time in Australia? I can't remember. Sorry. I remember. I was first a dietitian and I was handing over my plan to one of the doctors I mentioned refeeding syndrome and Arendt mentioned about supplementing time in and stuff like that. And he says to me, refeeding syndrome doesn't exist. Do you think that has any? Where do you think that comes from? I've heard it from a few other sort of doctors, usually doctors, and usually probably even more senior doctors say it occasionally. Where do you think that comes from? And is there we know they're wrong? Obviously, because we're discussing refeeding syndrome. And however, where do you think that probably comes from? Do you think it could come from a lot of clinicians being overly cautious and being warned about it about 100 times and never seeing it in better bias? I think for a lot of these doctors have been very lucky that either their dieticians have been on top of it. And if the patients on feeds have started quite slowly and built up, or they're lucky if the patient's on oral nutrition and just gradually started eating more on their own without sometimes you do see patients that go from zero to 100 when they're on oral nutrition, but I do in my opinion, it's quite rare, not as rare as some of the stuff we're talking about. But I also think there is an aspect of the boy that cried wolf, when I was a student, the number of times I had to pay the doctor to tell them that I thought a patient was at risk of refeeding syndrome was borderline ridiculous. Like, I can't believe I used to harass the medics so much. Whereas now I would barely page so generally, we're actually very lucky in the health service that I'm in and our doctors are very aware of refeeding syndrome. Our patients that are have eating disorders or automatically started on supplementation. And I think it's I think it's a good thing that they're obviously I think it's a good thing that they're very aware of it so I don't have to page them but it's also come with experience that not everyone is at risk just because they meet that nice criteria that I've Yeah, I think it does come with clinical practice. It comes from having good supervise arises it comes with thinking really objectively about where these where the criteria have actually come from and what supporting Yeah, I think for the people that say it's not real, I always argue, tell me, how come the prisoners of war dropped dead? But there is also an aspect of, yes, we do, yell and shout about it a lot, which would get on their nerves. And I don't blame them to some degree. Definitely. So you mentioned a little bit around refeeding syndrome was definitely common common in prisoners of war when they started eating, and it was well done. It was documented and it was seen, but we don't see it as much today in our modern medical systems with the monitoring and the supplementation and things like that. What do you think makes the biggest impact from those two different settings? Is there anything that makes the biggest impact? Or what would you say makes the biggest impact when trying to manage refeeding syndrome? So primarily, biggest impact is, before we even get into the hospital system, there's a support most people like they have family or they have friends checking in on them, they have a neighbour that's aware that there's that there could be something wrong and that sort of thing. So I find that don't see that many patients come through the health care service that have been neglected and staffed for months and months on end, which is what our prisons have what went through in the hospital, I actually think it comes down to the fact that we can get blood results within a couple of hours. And we can give some electrolyte supplementation very quickly. I think that's our, like our biggest tool in our toolbox like diamond supplementation, multivitamin supplementation is important. But I really do think it's monitoring what's actually happening in this person's body and being able to fix it quickly. So that's the monitoring the electrolytes and those sorts of things actually made the biggest difference over all the other things. Yeah. Yeah, we looked at in our health service, once I finished my PhD, we changed our refeeding syndrome guidelines quite drastically. And it didn't make a difference if we fared really fast. And I think that come it's so it's not, I don't think it comes down to what we're what Nutrition has provided. I think it's all the other things that come into it. Yeah, I always preach that. If you think someone's at risk, make sure there's daily blobs, like minimum for four days, and most of the guidelines, say 10 to 14, which I think is difficult in clinical practice. Because, you know, most of our patients, unless they're quite sick, aren't staying in the healthcare service for that. aren't staying in hospital for that long anymore. We're trying to reduce length of stay. So I think being realistic about what you can manage is important, too. So yeah, I do think it's all those medical, like, we need our medics to do blood tests. Yeah, definitely. Yeah. So carbohydrate is one of the biggest triggers of refeeding syndrome, is there any benefit to manipulating macronutrient composition. So for example, giving the patient a higher Fat Feed instead of a higher carbohydrate feed. Yeah, the research is quite limited in it in this sort of field. For me, I always say as long as it's balanced, so as long as you're not giving a patient, straight, glucose drinks all day, every day when they're at risk, then you shouldn't have a problem. There is definitely discussion in the eating disorder literature, that limiting carbohydrate to 40% is beneficial, especially when your intro during enteral feeds. We did our study a few years ago and carbohydrates 50%. And we had no cases of refeeding syndrome. So I think as long as there's a little bit of common sense there, like as long as it's not 100% carbohydrate load, and there's a bit of other stuff going on in there, then I think it's fine. And is there any difference between parenteral and enteral nutrition? I think my brain thinks that there's less risk of say enteral nutrition compared to parenteral. When we when I did my systematic review from my PhD, we actually found that the patients receiving enteral nutrition were getting most of the symptoms that sent a lot of the papers that we looked at because the definitions for refeeding syndrome are all over the shop, some of them were counting things like diarrhoea and that sort of thing, which when you're using enteral nutrition, I think is sometimes inevitable. So I do take that with a grain of salt. I think parenteral nutrition can be more I want to say harsh or are patients at risk of refeeding syndrome. So because it's it's straight in rather than going through the digestive system, but the literature doesn't support my thinking on that. So I wouldn't take All of what I just said with a grain of salt. Yeah, unfortunately, I don't think there's a clear cut answer on that one hour. And I'm sorry. So the literature is so all over the shop too, because you know, a lot of these studies are done in ICU where everything's protocolized, which is very different to being on a general ward is very different than being on a general ward. So yeah, definitely, there's a understanding the context of where you work in stuff, but it might be an area for research that obviously, as we're discussing all these gaps, I hope everyone's thinking there's an opportunity there, or there's an opportunity there and just always be looking for that opportunity thing. Yes, yeah, I always remind people that have a bit of a competitive nature with research. There's always so many topics. So if someone's nabbed something, there's always something else, especially in refeeding syndrome, exactly. From Carly's experience, I dare a dietetic student or a dietitian to do research in some of the areas that we'll discuss today, I dare you. And we'll see if they do it, because I want to get more people doing doing research to just prove people wrong and set the record straight. I think that's definitely a competitive nature. So I think a lot of the information discussed here for even when I was a new dietitian will be quite sort of earth shattering. Or what do I do now? How do I actually do this? Should I just feed everyone loads of calories? Am I just purposely not feeding them? How does this actually translate into practice? So when we go into managing Reif possible refeeding syndrome and our patients, how does that actually translate? What would you what do you think is a sensible way to approach practice? sensible ways, being sure if your medics, so being sure that they will supplement what's needed, they will do blood tests, there'll be all the monitoring that's recommended. So I think that sets the system up and allows the dietician to be a bit more, I want to say assertive or aggressive. When because the research is so poor, the study that we've done on our service is one of the more assertive types that are out there. And it's not with patients with eating disorders, it's just our patient that on the general ward, and we start at 50%. And if there's only mild or there's no electrolyte decreases, we actually go to gold within 24 hours. And we didn't have any adverse outcomes. With that, I will highlight that this was a three month audit. And we I think it was about, I want to say 90 patients in the end, so it's not huge. But we've had good outcomes from that. So I think it's, I'm not saying go in and do that exactly. Because that would just be adding my own got my Kiley guidelines out there with the 50,000 other guidelines that have different numbers and recommendations. But finding something that you're comfortable with. So when we were updating the refeeding syndrome guidelines for our health service as a department, we got together and we all talked about what we all individually do, because none of us were following the recommendations because we all felt that was so conservative. And then once we've been told did a poll on what everyone is doing, really kicks that around, we looked at what the evidence shows compared to what everyone else was doing. And that's how we came up with that cut what we were comfortable with as a service providing to our patients. So you can't do it alone. I don't think so. If you go rogue, someone's gonna read the chat entry and wonder why you're starting and doing something so assertive compared to the rest of the service. So I think it's important to have those discussions as a team. Definitely, I think, yeah, a team approach and then building the guidelines together, and basically what you all feel comfortable with. And just so there's uniformity. So when you're actually going when different dieticians cover, or different dietitians cover different services, there's not confusion or there's not. Yeah, it just helps with continuity and things like that, also, I think probably translate it is this is a massive area for research a massive area of development. And the only way we can alarm has to say, improve the guidelines. And the evidence behind them is by create getting more evidence getting more even audits or actual practice of what dietitians are doing in practice and how it impacts patients. So that's obviously an area where we can collect data and and I know Allison from the UK is very bullish on this and patients at risk of refeeding syndrome. She's particularly bullish, and she keeps on saying, Let's collect evidence, keep on collecting evidence, the more we have, the better and obviously you might think I don't have the capacity to do X type of study or the dream study or whatever. But I think with everything, it's just collecting as much evidence as possible because I love Allison, I've talked to her about this before, like, I really want to do an RCT but in our service here, it's just it's impossible and she's always turned around and said it's not impossible. There's a study published you can totally do it. So like to tell people that like Don't ever think it's impossible because someone has just done it. And it needs to be replicated. And the poor things have so many problems with their study as well, just with delays and that sort of thing, definitely need some more work out there as well. Definitely, I'm so grateful that you obviously did your PhD in this topic. And hopefully, it's been really informative to those who are dieticians and student dieticians out there to really understand a little bit more about refeeding syndrome. And I think that's the push going forward. I think, as we can see from I mentioned the beginning of the pench handbook, from quite prescriptive guidelines to displaying the evidence and you pick for yourself and looking actually reading the studies. And that was very much encouraged when we went through collating requirements, which is a story for another day, around evidence and gaps in evidence. But definitely the opening sort of accident. To be honest, a lot of dietitians that I talked to at the time, were quite frustrated with actually they were like, how is this clear to read? How do we tell people what to do? This is going to be really problematic for students. And it's not prescriptive, and it's quite difficult to understand. But I think moving more towards that actually understanding what's behind the guidelines, actually helps people to be more informed practitioners. I think it's so important to understand what is actually behind certain guidelines. And I think what your talk did originally, and what some of this podcast has done is help inform me personally, around what's actually behind the refeeding guidelines. So when I'm implementing it, or actually using the guidelines, I understand the evidence and how much evidence is behind it. Thanks. Yeah, look, it was a learning curve for me too. I remember reading our level C level D evidence. Okay. So that means it's pretty rubbish. But then when you dig down deep into it, you're like, Oh, okay. There's really no studies. It's it is expert opinions. Yeah, I do think it's important. We do journal club at work quite regularly, and we rip apart guidelines all the time. It's fun. Just rip them apart, looking at what's supporting them. Yeah. And I highly recommend so. I mean, yeah, it's a really good practice to do rip apart guidelines and look at what's actually behind them. I think it's it just Yeah, it is really important. I think that's vital. But thank you so much for coming on the podcast.

Thank you for having me on. It was fun.